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Will bowel cancer screening policy failures be an election issue?

An indictment of federal health policy-making (under successive governments and health ministers) has just been published in this article tracing the history of bowel cancer screening in Australia.

Amongst other things, the paper reveals apparent communication breakdowns between the Department of Health and Ageing  and the Department of Finance and Administration about the costing of a bowel cancer screening program. As a result, an appropriate allocation has never been made to enable proper implementation of the program.

There have been many other glitches and missed opportunities. As the University of Sydney researchers note in the Medical Journal of Australia: “Political, financial and institutional constraints combined to shape and limit the National Bowel Cancer Screening Program.”

The paper’s lead author, Kathy Flitcroft, Research Fellow with the Sydney School of Public Health’s Screening Test and Evaluation Program, has provided this analysis for Croakey readers.

She writes:

“Cancer accounted for 29 per cent of all deaths in Australia in 2007. The latest report by the Australian Institute of Health and Welfare has revealed a projected 10 per cent rise over just four years in the number of new cases of cancer, and, according to Health Minister Nicola Roxon, cancer is placing “an intolerable burden on the community.”

The main reason for this projected rise in cancer incidence is the growth in population of those aged 60 years and over, the same age group most likely to develop bowel cancer.  An effective bowel cancer screening program could help reverse this cancer rate increase.

Bowel cancer is a serious health problem in Australia.  The latest figures reveal over 13000 new cases of bowel cancer per year, and over 4000 deaths from this very preventable disease. This makes bowel cancer the second most common cancer in Australia behind prostate cancer and the second biggest cause of cancer death in Australia behind lung cancer.

Bowel cancer is a natural candidate for a screening program as it is generally a slow-growing cancer that if found and treated in its early stages, has a high cure rate. A Faecal Occult Blood Test (FOBT) screening works by detecting the presence of blood in the large bowel, which is the major indicator of possible bowel cancer.

The National Health and Medical Research Council recommends biennial FOBT screening for those over 50 years of age, but the Australian government has not yet committed to implementing a full screening program.

Government justification for the limited roll-out of the bowel cancer screening program has been based on the need to ensure that there is adequate colonoscopy capacity to allow for prompt follow up of positive FOBTs. However, 450,000 colonoscopies are currently performed in Australia per year, mostly in the private sector, and many are being performed for lower-risk indications.

If colonoscopy capacity was prioritised for those with positive FOBTs, overall capacity would not be a problem. What may be needed however, is a way of ensuring that those without private health insurance are not excluded from receiving prompt follow up, and this could be achieved by a voucher system which entitled all individuals with positive FOBTs to have a colonoscopy in either the public or private system.

So, why should the Australian Government get on with it and properly fund a full bowel cancer screening program?  The top five reasons are:

1)   One quarter of bowel cancer deaths can be averted through implementation of an evidence-based bowel cancer screening program.

2)   FOBT screening has been shown to actually reduce the incidence of bowel cancer, as removal of pre-cancerous polyps identified through colonoscopic follow up of positive FOBTs can prevent the disease from developing in the first place.

3)   Early detection can save individuals and their families the pain, anxiety and suffering associated with late stage bowel cancer, including surgery, radiotherapy and chemotherapy.  If cancer is detected before it has spread beyond the bowel, the chance of surviving for at least five years after diagnosis is 90%, and treatment options have much less severe impacts.

4)   Bowel cancer screening is cost-effective. Several studies have consistently shown that bowel cancer screening is very good value for money, and has become even more so with the recent changes to chemotherapy agents used to treat late stage bowel cancer. The costs of treating late stage bowel cancer have risen dramatically, making early detection an even better economic deal.

5)   Early detection can reduce the financial and administrative burden on health services by reducing the need for hospital stays, theatre time etc, a fact that should please the Australian government now that it is about to become a major hospital funder.

Australia offers comprehensive breast and cervical cancer screening programs that have contributed to reductions in deaths from these two diseases.  Both of these programs are world-class, well-patronised, systematically monitored and have continuing funding.

Yet, bowel cancer kills more people each year than both these cancers combined, and it has not received the same ongoing commitment to funding. There have been no funds allocated to the bowel cancer screening program beyond June 2011.

A long-term commitment to rolling out a full bowel cancer screening program is urgently needed.”

You can do something positive by going to the Cancer Council Australia’s website (http://www.cancer.org.au/Home.htm) and joining their Get Behind Bowel Cancer Screening campaign, which aims to make bowel cancer screening policy an election priority.

• Meanwhile, the prostate cancer screening wars continue in the journal, with two urological surgeons rejecting claims that PSA testing has been a “public health disaster”.

Comments 16

  1. virchow says:

    The advice to the feds by the various specialists involved in this program was ignored by governments of both parties. Those of us involved in colon cancer screening have known this for quite some time. I am gald that this is now getting the scrutiny it desreves. The feds get excellent advice on the cheap since many of the medical profession either do not charge or cannot charge the government for their advice. It is little wonder that it is routinely ignored by the politicians and the executive branch of the Canberra bureaucracy. Some of us have made submissions to senate inquiries into cancer screening pointing out that the federal government has failed to commission research relevant to the screening programs. For example, there is a pressing need for a trial into the use of HPV testing to replace the Pap test. The HPV test is a better test than the Pap test and the only means to address the problem of screening women who have been vaccinated against HPV. These women are already in the cervical screening program. So far, we have heard only stony silence from DoHA and minister Roxon. Even Britain which has barely a brass razoo to its name can commission decent sized studies into these problems and make the results freely available to everyone. In this respect Australia is nothing but a cheapskate. The politicians and DoHA want to claim the glory for the results of screening activities but they are remarkably reluctant to fund them properly. Relevant research to answer issues raised in cancer screening needs to be funded as part of the operating costs, which themselves need to be fully funded on the basis of good science not on the basis of political expendiency as is the current arrangement.

  2. virchow says:

    The MJA article mentions the difficulties in gathering data required to monitor the effectiveness of the screening program. This is because a POLITICAL decision was made that screening had to be part of everyday activities rather than a stand alone program where everything including Quality Assurance and data acquisition could be mandated. For example, the Breast Screen units can mandate QA and data acquisition for the screening component since this is part of a service agreement. When screening is part routine clinical practice these things are much more difficult to mandate. The definitive solution to data acquisition now awaits the electronic patient record which is decades away. As the authors of the MJA allude, the advice and evidence that Canberra and its politicians get appears to take second place to political and financial considerations with predictable results. Sadly, colorectal screening merely highlights and acts a metaphor for a deeper malaise affecting this large and important department and political portfolio.

  3. MTC says:

    Come on Health Authorities – spend the money, get the screening program moving, and we’ll save some lives – we’ve lost, and unfortunately, will lose more yet, due to procrastination about this insidious disease. It’s tough enough to get people to discuss it, without making it tough to get tested, and yet it’s curable and preventable!!

  4. Dacq says:

    It may sound overly cynical, but, it has been suggested to me that more FOBTs = more demand for the next stage of interventions (i.e.,sigmoidoscopy, colonoscopy) and the system couldn’t cope with a substantial increase in demand for these services. I found this interesting, esp. compared to what my family reports from the USA — home of ‘get what you pay for’ health care, where those who can afford it, belong to a health insurance plan/managed care group, etc., demand things like screenings. There, apparently, you don’t waste time with FOBTs but just go for a colonoscopy, which has the benefit of greater reliability (so I am told) and allows for any polyps to be removed there and then.

  5. Dacq says:

    Also: does anyone understand the delineation between the Dept of Health & Ageing and Cancer Australia on issues such as this?

  6. NT says:

    It doesn’t make sense not to screen for bowel cancer. It is a quick, easy, non-invasive, cheap test. Not only will it save lives it will also save money. Bowel cancer kills more people each year than breast and cervical cancer combined and they have screening tests.
    Stop the inaction and get on with it.

  7. Doctor Whom says:

    dacq

    yes a sudden upswing in demand for colonoscopies would stretch the system.

    However if a positive FOBT was required for a bowel cancer colonoscopy, in the absence of other indicative symptoms, then there would be less colonoscopy demand for initial screening which would free up space for those with positive FOBT to get colonoscopy.

    UK, which requires a positive FOBT (in absence of other symptoms) prior to a bowel cancer, has a colonoscopy usage rate 4 times, Yes 4 times, less than that of USA and Oz. UK has bowel cancer outcome rates no worse than USA or oz.

  8. Doctor Whom says:

    I meant:
    UK, which requires a positive FOBT (in absence of other symptoms) prior to a bowel cancer COLONOSCOPY, has a colonoscopy usage rate 4 times, Yes 4 times, less than that of USA and Oz. UK has bowel cancer outcome rates no worse than USA or oz.

  9. Kathy says:

    In response to Dacq, I would like to note the following. A screening program using FOBT actually limits the demands on the health system by only offering colonoscopy to those with a postive FOBT – blood in faeces is the best indicator of possible bowel cancer, so testing people for the presence of blood first, and offering colonoscopy to those who test positive, makes better use of resources. Also, because there are risks associated with colonoscopy, mainly bleeding associated with removal of polyps, it makes sense to limit this procedure to those most at risk from bowel cancer.

    Cancer Australia is a government body which aims to coordinate cancer programs nationally. They do not deal with screening specifically, but look at the full spectrum of cancer control issues – so prevention through diet, exercise etc, early detection, diagnosis, treatment, palliative care etc. They also fund cancer research and professional training. More information about what they do is available from:
    http://www.canceraustralia.gov.au/cancer-australia/about-us/about-us

    DoHA has a screening section which is responsible for all national screening programs, not just cancer screening, eg newborn screening, early childhood screening etc. The screening section oversees the three existing cancer screening programs – breast, cervical and bowel. It contracts out the management of screening registers and the reporting of results and evaluation of programs. It also takes responsibility for investigating potential new screening programs and conducted the breast and bowel cancer screening pilots.

  10. Dacq says:

    Dr Whom, Kathy, Virchow et al – Your comments were very useful. I have been a DoHA bureaucrat and seen how it works. (A broom should have been put thru there years ago, starting at the top: a serious cultural change is required. The top-down influence of the Howard years took its toll.) Sadly, bowel cancer screening is not the only casualty. I am aware of other major policy initiatives constructed around good evidence which were subsequently hacked to pieces because they didn’t fit political objectives.

  11. Croakey says:

    Dacq, please tell us of the other policies that were hacked to pieces. What, when, why, how, and who? (the usual journalistic queries…)

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